Robotically-Assisted Myxoma Resection: Tips and Tricks

This video demonstrates the technique for robotically assisted myxoma resection. Also, it highlights the tips and tricks that have made this approach the authors’ method of choice for nearly all patients. The patient was a 72-year-old woman who had a routine chest CT, which showed an incidental LA mass, as demonstrated in this image. She had neither heart failure nor constitutional symptoms. She also denied a history of embolic events.

The preoperative transesophageal echocardiography showed a left atrial mass attached to interatrial septum, highly suggestive of a left atrial myxoma, as demonstrated in these images. This is the safety algorithm for robotic surgery developed by the authors’ team. Echocardiography and chest, abdomen, and pelvis CT are performed in all patients. The assessment is based on three key components: 1) what the heart looks like, 2) the risk of stroke, and 3) anatomic feasibility. Regarding the heart, patients are excluded if they have either LV dysfunction or dilation, CAD and AS requiring treatment, or pulmonary hypertension. Furthermore, the authors exclude patients who have more than 1+ AI due to concerns with myocardial protection during antegrade cardioplegia delivery. The second key component is the risk of stroke due to retrograde perfusion. The authors exclude patients with moderate to severe aortoiliac atherosclerosis disease. However, alternative perfusion techniques may be applied. The last component is the anatomic feasibility. They don’t offer this approach for patients who have moderate to severe pectus excavatum, which displaces the heart or small arteries due to cannulation concerns.

The patient in this video met the authors’ preoperative safety criteria for robotically-assisted surgery. Their experience shows that most patients with myxoma fulfill this algorithm and therefore are candidates for this approach. The patient was positioned supine with the right chest in 30-degree rotation, and the right arm slightly abducted to expose the axilla. The authors drew the midclavicular and anterior axillary lines on the patient skin as reference points. Also, they mark the nipple as inadvertent nipple cut has been described in males. In females, the breast is pulled upward and to the left to approximate the breast fold to the 4th intercostal space. After prepping and draping, they first performed the femoral cutdown to assess femoral vessel quality before committing to the robotic approach. After the vessels were deemed cannulatable, a 4 cm long incision was performed anteriorly to the anterior axillary line on the fourth intercostal space (ICS). In a woman, the authors make the incision at the breast fold and tunnel it to the fourth intercostal space if need be. If the left pulmonary hilum was easily visible, the correct intercostal space was likely entered. Diaphragm stitch for retraction may be required if the diaphragm sits high in the chest cavity. Next, they place the robotic ports. The right arm port was inserted on the sixth ICS, where it crosses the anterior axillary line. The left atrial retractor arm port was placed on the fourth ICS, where it crossed the midclavicular line. The right arm port was inserted on the second ICS at the place, where it creates an equilateral triangle. Ideally, this triangle is the base of a virtual pyramid that has its tip on the pulmonary hilum. Also, the authors make four holes posterior to the anterior axillary line. The first hole is at the third ICS, and they insert the cross-clamp though it. The other holes are to add a left atrial vent and two angiocaths for pericardial stay sutures. This picture depicted the final set up before cannulation and initiation of cardiopulmonary bypass.

The following key steps are performed in all patients as they increase not only safety but also efficiency. The authors open the pericardium only after initiation of CBP to decompress the heart. They also apply two pericardial stay sutures to pull the heart and the aorta towards the working port. This maneuver facilitates aortic manipulation under direct visualization. Also, both the cardioplegia catheter insertion and the cross-clamp are applied during low flow state to avoid the potential risk of dissection and bleeding. Lastly, they give long-acting single dose antegrade cardioplegia to avoid redosing and retrograde cardioplegia delivery.

After the cardiac arrest and the docking of the robot, the left atrium was opened in the standard fashion. The retractor was placed toward the roof of the left atrial to avoid tumor fragmentation. The left vent was inserted and the atriotomy extended. Then, the LA retractor was adjusted accordingly. The robot allowed for unparalleled magnifying visualization. Also, tumor handling was more precise due to its increased dexterity. The combination of superior visualization and precise tissue handling allowed for accurate dissection of the subendocardial plane, which lead to en-bloc resection of the tumor and its attachment site without tumor fragmentation and creation of atrial septal defect, as shown here.

During the closure, a few strategies were performed to increase efficiency and safety. Two pre-formed looped PTFE sutures were used to close the atriotomy. PTFE suture slides more smoothly through the atrial wall, allowing better tissue approximation. The pre-formed loop avoids knot tying at the corners of the atriotomy, increasing efficiency. After deairing and cross-clamp removal, the bedside assistant tied the PTFE suture. The left atriotomy was reinforced with two 16 cm long 4-0 Prolene. Each Prolene runs from the center to one corner and back to the center where it is robotically tied. Lastly, a 4-0 Prolene purse string suture was applied to the cardioplegia site as a safety net.

The postoperative transesophageal echocardiography showed normal ventricular and valve function and intact interatrial septal. The authors discharged the patient on day four. Myxoma resection done with a robot is a safe and effective operation. Simple modifications on the technique increase safety and efficiency. Robotic surgery has not only the benefits of minimally invasive surgery but also allows for better tumor handling, visualization, and resection. Therefore, the authors believe robotic myxoma resection should be the treatment of choice for nearly all patients.

References

1. Gillinov AM, Mihaljevic T, Javadikasgari H, Suri RM, Mick  SL, Navia JL, et al. Early results of robotically assisted mitral valve surgery: Analysis of the first 1000 cases. J Thorac Cardiovasc Surg. 2018;155(1)82-91.e2.
2. Malas T, Mick S, Wierup P, Gillinov M. Five maneuvers to facilitate faster robotic mitral valve repair. Semin Thorac Cardiovasc Surg. 2019;31(1):48–50.
3. Yang M, Yao M, Wang G, Xiao C, Wu Y, Zhang H, et al. Comparison of postoperative quality of life for patients who undergo atrial myxoma excision with robotically assisted versus conventional surgery. J Thorac Cardiovasc Surg, 2015;150(1):152-157.

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